Use of Therapeutic Neuroscience Education to address Psychosocial Factors Associated with Acute Low Back Pain: A Case Report

Use of Therapeutic Neuroscience Education to address Psychosocial Factors Associated with Acute Low Back Pain: A Case Report Physiotherapy Theory and Practice (in press) Kory Zimney, PT, DPT, CSMT

YOUR historical path Maitland McKenzie Butler Upledger Paris Barnes Janda Kolar Cook Gray Lee Hruska

Find it; Fix it

Our Paradigms our Outdated

Please just look at the light

Efficacy Neuroscience Education Louw A, Diener I, Butler DS, Puentedura EJ. The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Archives of physical medicine and rehabilitation. Dec 2011;92(12):2041-2056.

Brief psychosocial education, not core stabilization, reduced incidence of low back pain: results from the Prevention of Low Back Pain in the Military (POLM) cluster randomized trial George et al. 2011 Conclusions: Core stabilization has been advocated as preventative, but offered no such benefit when compared to traditional lumbar exercise in this trial. Instead, a brief psychosocial education program that reduced fear and threat of low back pain decreased incidence of low back pain resulting in the seeking of health care. Since this trial was conducted in a military setting, future studies are necessary to determine if these findings can be translated into civilian populations.

What about Acute Pain

My patient with acute LBP 19 y/o female, CNA at a nursing home 1 week post LBP from injury while lifting a patient Pain 3/10, 7/10 at worst Occasional pain down leg ODI 36%, FABQ PA =23, FABQ W =30

All Low Back Pain is not the same 10% of the claims lead to 86% of the costs.(hashemi et al. 1997)

Early Predictors of Chronic Socio-demographic Employment related Pain and function Clinical status Health care Administrative/legal Health Behaviors Psychological Work Disability Turner, J., et al. (2008). "Early Predictors of Chronic Work Disability. A Prospective, Population-Based Study of Workers with Back Injuries." Spine (Phila Pa 1976) 33: 2809-2818.

Early Predictors of Chronic Work Disability Self-reported physical disability seems to be more important than pain intensity in predicting work disability duration. Psychological variables such as mental health, fear avoidance, and catastrophizing factors were strong predictors

Early Predictors of Chronic Work Disability Accommodated work 2 x the odds of chronic work disability if not offered within first 3 weeks

Injury Severity Early Predictors of Chronic Work Disability Pain and Function Questionnaires Radicular pain Without reflex, sensory or motor loss 2x more likely to be disabled With reflex, sensory or motor loss 3.7x more likely to be disabled

Early Predictors of Chronic Work Disability Psychosocial factors Supervisor/employee relations Heavy lifting requirements Hectic work pace

Yellow Flag Questionnaires Keele STarT Back Screening Tool Acute Low Back Pain Screening (ALBPS) Questionnaire Medium Risk

Acute Low Back Pain Screening (ALBPS) Questionnaire 21 item questionnaire High risk group with a score of greater then 105 score can identify about three quarters of long term cases 90-105 at medium risk candidate for long term cases

Variables Present Is your work heavy or monotonous? Patient answer = 10 (10 = extremely) How would you rate the pain that you have had during the past week? Patient answer = 7 (10 = pain as bad as it could be) How tense or anxious have you felt in the past week? Patient answer = 7 (10 = As tense and anxious as I ve ever felt) In your view, low large is the risk that your current pain may become persistent? Patient answer = 4 (10 = very large risk) An increase in pain is an indication that I should stop what I am doing until the pain decreases Patient answer = 10 (10 = completely agree)

Discriminating variables Heavy or monotonous work Previous sick leave Current pain intensity Light work availability Perceived chance to be working in 6 months Belief that one should not work with current pain levels Stress

Back to our Patient for the Subjective and Objective Exam Thinking, worrying, uncertainty, questions, anger, frustration

Subjective Examination 23

Fear Avoidance Model

Could also be emotional overload Pull back Do less Increased fear Choice made Importance of early education? Irrational thoughts Knowledge Limited knowledge Threatening and provocative words; Medical tests; Various opinions; Internet information; Experiences

Objective findings No red flags but did have yellow flags and medium risk for persistent pain Range of Motion and Movement Quality Decreased bending in all motions with no directional preference Pain and apprehension with all movement Aberrant movements with transitional movements (i.e. sit to stand, supine to sit)

Neurodynamics Relevant neurodynamic tests Slump + on right with knee at 30 degrees SLR + on right at 50 degrees Sidelie slump No myotome, dermatome or reflex deficits

SI provocation tests Distraction + Thigh trust + on right - on left Gaenslen s + right and left Compression - Sacral thrust -

Palpation and Segmental testing Hyperalgesia with touch to Low Back Questionable Hypomobility of lower lumbar

Prone Hip Internal Rotation Right 20 degrees Left 45 degrees

Potential Structures Involved? Lumbar musculature Lumbar ligamentous structures Right lower lumbar facet joints Right SI joint Lower lumbar discs Lumbo-sacral plexus neurodynamics

Diagnosis?

No, Keith Smart

Mechanisms Based Classification Nociceptive Chemical and/or Mechanical Peripheral Neurogenic Central

Let s Treat with EBP Super Fix It 5000 Clockwise or Counter Clockwise?

Clinical Prediction Rule s? Lumbar Stability? Lumbar Traction? Lumbar Manipulation?

Consider ALL therapy this way BOTH

A Few Therapeutic Possibilities NUEROSCIENCE EDUCATION TACTILE/ SKIN MOVEMENT/ BLOOD FLOW BODY PARTS BODY SPACE REDUCE THREAT

Therapeutic Neuroscience Education If the primary complaint is PAIN why educate patients about anatomy and biomechanics? Why not just teach them more about.pain? Image: Clinical Journal of Genius 2012

Brief psychosocial education, not core stabilization, reduced incidence of low back pain: results from the Prevention of Low Back Pain in the Military (POLM) cluster randomized trial George et al. Conclusions: Core stabilization has been advocated as preventative, but offered no such benefit when compared to traditional lumbar exercise in this trial. Instead, a brief psychosocial education program that reduced fear and threat of low back pain decreased incidence of low back pain resulting in the seeking of health care. Since this trial was conducted in a military setting, future studies are necessary to determine if these findings can be translated into civilian populations.

1. Validate tissues got Injured, Assure them they will Heal!!! 2. Nerves got sensitive, they will calm down!!!

4 Questions a Patient Wants Answered 1. Doc, what s wrong with me? 2. Doc, how long s it going to take to get better? 3. Doc, is there anything I can do to help myself? 4. Doc, is there anything you can do to help me? Louis Gifford, forward Therapeutic Neuroscience Education: Teaching Patients About Pain.

Doc, what s wrong with me?

Nociception

Tissues get injured, Tissues HEAL!!!!!

The Nervous System Louw, A and Puentedura, L; Therapeutic Neuroscience Education: Teaching Patients About Pain. A Guide for Clinicians. 2013

Your Alarm System: Normal

Alarm System

Specific to your situation

Critical Part 1. How do you know this? 2. Why did they stay up there? 3. How do we calm it down?

Nerve Sensors and Sensitive Nerves

Waking up the alarm system Motion Detector Lights Car Sensors

Waking the Neighbors Louw, A; Your Nerves Are Having Back Surgery. 2012

The Police Louw, A; Your Nerves Are Having Back Surgery. 2012

Waking up the alarm system Why Do I Hurt?; Louw 2013 OPTP

Doc, how long s it going to take to get better?

A Few Therapeutic Possibilities NUEROSCIENCE EDUCATION TACTILE/ SKIN MOVEMENT/ BLOOD FLOW BODY PARTS BODY SPACE REDUCE THREAT

Tissue Recovery

Pain Recovery

Altering Beliefs Decreased cortical activation

Doc, is there anything I can do to help myself? Education know pain, know gain Exercise motion is lotion / sore but safe Medication

A Few Therapeutic Possibilities NUEROSCIENCE EDUCATION TACTILE/ SKIN MOVEMENT/ BLOOD FLOW BODY PARTS BODY SPACE REDUCE THREAT

Endogenous Mechanisms Know pain = Know gain

A Few Therapeutic Possibilities NUEROSCIENCE EDUCATION TACTILE/ SKIN MOVEMENT/ BLOOD FLOW BODY PARTS BODY SPACE REDUCE THREAT

Pacing/Graded Exposure Edge Work Moseley, G. L. (2003). "A pain neuromatrix approach to patients with chronic pain." Man Ther 8(3): 130-140.

Home Exercises

Doc, is there anything you can do to help me?

A Few Therapeutic Possibilities NUEROSCIENCE EDUCATION TACTILE/ SKIN MOVEMENT/ BLOOD FLOW BODY PARTS BODY SPACE REDUCE THREAT

Stolen with permission in kind from Diane Jacobs, PT

Follow up Visits Visit 2 and 3 TNE as needed to reinforce main message Continue progression of manual therapy with joint mobs and soft tissue techniques. Exercises for motor control and awareness of movement Visit 4 and 5 Decrease in manual therapy Trunk strengthening and functional lifting

Outcomes Functional Measurements Initial 1 week 2 week (D/C) Lumbar Range of Motion: Flexion 15 30 60 Lumbar Range of Motion: Extension 5 15 25 Standing tolerance 20-30 minutes 1-2 hours unlimited Lifting tolerance 10# 15# 50# Outcomes Questionnaires Initial Discharge ODI 18/50 0/50 Numeric Pain Score 3/10 0/10 FABQ (PA) 23 0 FABQ (W) 30 0 Keele SBST 4/9 0/9 ALBPS Questionnaire 101 0 PSFS 4/10 10/10

Pain is a protective mechanism developed by the brain based on how it interprets information General Conclusion Feeding the brain better information seems key to alter pain.

Case Report Conclusion The use of TNE with a patient with acute LBP appeared to prevent the development of persistent pain problems, especially in this at risk patient.

The Best Way to Treat Persistent Pain? Prevent it!!!

Thank you & acknowledgements Kory.Zimney@usd.edu Adriaan Louw PT, M.App.Sc (physio), GCRM, CSMT Emilio Louie Puentedura- PT, DPT, PhD, OCS, GDMT (Australia), FAAOMPT, CSMT ISPI staff and faculty